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HomeMy WebLinkAboutBuilding Permit # 6/22/2015 IJIL I PERMIT F �o�rH � T NORTH ANDOVER x�® gtL@D ® APPLICATION FOR PLAN EXAMINATION '` m 64 Permit No# Date Received �RppRgT�o�PPa"Ry C NU5�R Date Issued: I PORTANT: Applicant must complete all items on this page LOCATION �C / tea 5 lee 2-- Print PROPERTY OWNER Print VO Year Structure yes no > MAP PARCEL: ZONING DISTRICT: Historic District yes Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building E One family ❑ Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Pf�epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other o - e r<rrr N r rr,. /, ii r r✓/ r r r../r lrr'r./ r ,. /, / // / / r / i/ ,, r r,, r ✓ ,,, r, /rf r /,o,,d,!/„r/ / �///lJ//,,. / / /r� l � /r/ r / �, ✓ r , i /,% �' o, l/ rr,�,, r , , , � ds, , /, /,� ❑/Wat'es r /. ti DESCRIPTION OF WORK TO BE PERFORMED: A 00 Identification- Please Type or Print Clearly OWNER: Name: V ev;lr Phone: 5"` Address: �W,0,l"e.5S Contractor Name: , � �,, '4, e Phone: Email: Address: 1/3&, /6 'r °° w � ' 0f Supervisor's Construction License: C, S °m C b, , Exp. Date: 10 1 X2,2 Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 20.z FEE: $ °M r Check No.: Receipt No.: E: , Persons conn cng wrtli c�nregastered contractors c10 not have access to t1t guaranty fu c1 I ttORT j w o �. ...'.q.� ®V C1 / 0 0 • "cam C% h ver, Mass, 2_2 I +}1 COC1412NHWlCK sP¢,�Acl � U BOARD OF HEALTH Food/Kitchen \ Septic System PERMIT T LD THIS CERTIFIES THAT ............�1 r.... .. . .................� g�—� —.... ................... BUILDING INSPECTOR .... .. . .. .. Foundation has permission to erect buildings on . ....jer'.t .. ... ..................... Rough to be occupied as ........ ....a.. ..... .......................................................... ... .... ......... chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final MONTHSPERMIT EXPIRES IN 6 ELECTRICAL INSPECTOR UNLESS I RTS Rough )114 Service ............... . ........................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. l� M E R I C A C'+1 0 /o6li� CABINET 436 Broadway Methuen,MA 01844 978-687-6825 bill To: North Andover Housing Authority i Moresk;Meadows North Andover,MA oi845 978-682-3932 PROPOSAL-29)3aldwin St. _1__............ _� Contractor's Choice New rry�i'rch...... ..... .. .........._..... •• Finish:Autumn ------ - - Scar�dard t=or�tr�action Sq are Edge Laminate 1 •Travertine=# sa6.5g _.._... . _...._ __._._... ... . -..........._. ..... 1 . 4 tneh Hackspias>a ___ ---------- _... - [Hardtvaaue •-� . ...66.001 _Allison Allison Pulls# bt -fiB fr __ _ ._. -•---•...___...... ... i ....._.. , _. ._.. c 7 .•__.............. . ........._.._...... _.__............. �. ! Ta� f Tax Exempt# o�zgz7z48 _. .. - --.. . . _........ . j — l ..Delivery ___......... Cabinets only;does not include disposal of cardboard Please sign and date below to confirm shown above and return a signed copy to American Cabinet to place your order. .A,50%deposit is required at time of order. The remaining balance is due upon delivery. Please understand that,by signing this proposal,you will not be allowed to cancel or return all or part ofthis order. Price is subject to change once a,field measurement has been taken, Signature: Date: -10717 W1230- W3018 W3930 I P 00 ` O E -- I d co CU co IN 29 Baldwin St, lbii dimensio>s' size deslinEitiom �ip This is an original dtsign and tnuA DeMgnod:Sl3t2015 grvnn are:tubjcet t4 voelfloation on 1ECMNOto01F.5 notbc relemsed br copied unless Pdnt©d:516/2015 jai}site and ndJuctmvnt to EitJob SyrillFcablc f©e ha titcn paid ar job conditIrms, order rl.cccd. i • The Commonwealth of Massachusetts ,Department of-Industrial Accidents M �.= 1 Congress Street,Site 100 a - d02114 20.77 Boston,MA www.mass.gov/dza G^M 5y'y� Workers' Compensation Imuraned Affidavit:Builders/Coutxactoxsll lectricians/Plumbers. TO BE FILED WITH THE PET'MC' RW AUTH""Ty- ' -Please Print Le ' A ''licant lnfoxmation Name,(Business/organizationlTndividual): . cal a 6 -�f'�'' G-.r /OT��� ho #: �L / C7 City/State/Zip: Are you an employer?Checic the appropriate box: Type of project()recluixed); em to ees $sill and/or part time).x 7. p New COnstrUCtioJ7 l, m a employer with___ ._._ P y 2.[:]1 am a sole proprietor oz partnership and have no employees�torking for mein $. Remo deli]tg any capacity.tNo workers'comp.insurance required.] 9. ❑Demolition 3.[:]lam a homeowner doing all work myself[No workers'comp.insurance required.]t 10❑Building addition <11 am a homeowner and will be hiring contractors to conduct 811 work on my property. 1 will 11.❑Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or aro-solebin repairs Or additions proprietors with no empldyees. _,I pr g 5.❑1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13'.0 Ro6f repairs These sub-contractors have employees and have workers'comp.insurance.t 14. Other 6.Q We are a corporation and its.officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no empldyees.[No workers'comp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. all workand then hire i Homeowners whoeck this box must attached avit an additional g they are sheegshowing thetside co of the sub-contractors and state wntrartors must heth r or reow pot those entities,have such. tContractors that h employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. f am an employer that is providingworkers'compensation insurance for my employees. Pelow is the policy and job site information. — Insurance Company Name: "rte gam" ` nn q Expiration Date:. 3 Policy#or Self ins. Lic.#: �-' ® % L ° p,, City/State/Zip: � 1 Job Site Address: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). on punishable by a&b up to$1,5 Failure to secure coverage as requiredunder il penalties inthe form o£a25A is a r aSSTOPat iWOIRK ORDER.and a fine of p to $200-00 50.00 a and/or one-year imprisonment,as p day against the violator.A Copy of this statement may be forwarded to the Office of Investigations o£the DIA for insurance coverage verification. Xdo hereby cert red ie_p s andpenalties ofpeljury that the information provided above is true and correct Date: � Si afore: Phone#: Official use only. Do not write in this area,to be completed by city or town official. Permit/License City or Town` # Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#` Contact Person` DATE(MM/DD/YYYY) ACGPRJY CERTIFICATE OF LIABILITY INSURANCE 6/19/2015 lIft .e— THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. . IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT M P ROBERTS INS AGCY INC PHONE (g78) 683-8073 FAX (978)683-3147 1060 Osgood Street —AReADDssFau allmprobertsinsurance.cam North Andover, MA 01845 INSURER(S) AFFORDING COVERAGE NAIC# INsuge86,MERCHANTS INSURANCE GROUP INSURED AMERICAN CABINET CORPORATION INSURER B:MERCHANTS INSURANCE GROUP 436 BROADWAY .MERCHANTS INSURANCE GROUP METHUEN, MA 01844 INSURER D:MERCHANTS INSURANCE GROUP INSURER PHILADELPHIA INSURANCE COMPANIES SU E '... COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFF POLICY D%EXYLTR TYPE OF INSURANCE SD D MDLIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE s 2,000,000 '.. CLAIMS-MADE El OCCUR PREMISES Eaoceu a cel $ 500 000 '.... X PRIMARY & BOP9101008 08/01/1408/01/15 MED EXP(Anyone arson $ 5 000 A NON—CONTRIBUTORY Y Y PERSONAL&ADV INJURY s 2 000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s 4,000,000 ROTHER: $ POLICY PRO- JECT 1:1 LOC PRODUCTS-COMP/OPAGG s 4 000 000 '......... AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,600,56 ANYAUTOBODILYINJURY(Per person) $ X ALLOWNED SCHEDULED CAPI055962 08/01/14 08/01/15 B AUTOS AUTOS Y BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED _ PROPERTY DAMAGE $ '.......... AUTOS era AUMBRELLA LIAB X OCCUR EACH OCCURRENCE s 3,000,000 EXCESS CLAIMS-MADE y CUP9144013 08/01/1408/01/15 AGGREGATE $ i , DED X 10 000 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY TA LIT' ER ANY CRN ?XECUTIVE Y WCA9097934 08/01/1408/01/15 EACH ACCIDENT , ,OO D OFIIEMEMBER EXCLUDED N/A y (Mandatory ) E.L. FASEEA EMPLOYEE $ 1'A0A'0 If ,describeunder 110001000 '......... E EPLI PHSD963395 07/29/1407/29/15LI: $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,AdditionalRemarks Schedule,may be aftachedif more space is required) JOB: 29 BALDWIN STREET NORTH ANDOVER MA 01845 NORTH ANDOVER HOUSING AUTHORITY IS LISTED AS AN ADDITIONAL INSURED IN RESPECTS TO GENERAL LIABILITY COVERAGE. CERTIFICATE LDE NORTH ANDOVER HOUSING AUTHORITY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1 MORKESKI MEADOWS THE EXPIRATION DATE THEREOF, NOTICE W LL BE DELIVERED IN NORTH ANDOVER MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED R TATIVE '... .'Ji00U ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD